The Alaska DV 101 form is a crucial document used in domestic violence cases to request a protective order and establish child support. This form requires detailed information about the parties involved, including income and health care coverage for children. Completing this form accurately is essential for ensuring the protection and support of those affected by domestic violence; click the button below to get started.
IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT
PETITIONER (protected person),
M
Birthdate:
Petitioner is a child. Who is signing for the child?
Name:Birthdate: Relationship to child:
)
F)
v.
RESPONDENT (restrained person),
Birthdate
Respondent is a child. Who is signing for the child?
) Case No.CI
) CHILD SUPPORT INFORMATION
INSTRUCTIONS. If child support is requested in a petition for a long-term domestic violence protective order, each party must complete one of these information sheets and bring it to the court hearing on the protective order or file it with the court before that hearing. If you need help filling out the form, a court clerk can help you.
Provide information about yourself and, to the extent it is available, about the other party. A court clerk can notarize this document for you at no charge. The information in this form is required by Civil Rule 90.3 and the statutes listed at the bottom of this form. If you want a copy of Civil Rule 90.3, ask the clerk for a copy of the booklet about child support, DR-310. The rule is in the back of the booklet.
Each party must attach a copy of his or her most recent federal tax return and most recent pay stubs to verify income and deductions.
AFFIDAVIT
I swear or affirm under penalty of perjury that the following information is true to the best of my knowledge and belief.
I.Other Child Support Orders
There are no other child support orders currently in effect concerning the children involved in this case.
The following child support order(s) concerning these children is/are still in effect:
Case No.
Effective Date:
Page 1 of 4
Civil Rule 90.3
DV-101 (6/11)(cs)
AS 25.27.062(a)
CHILD SUPPORT INFORMATION
AS 25.27.060(c)
II.Income Information. The following income and deductions are
monthly
yearly.
I have attached a copy of my most recent federal tax return and pay stubs to verify this
information. [Note: Delete social security numbers and account numbers from any documents you attach.]
PETITIONER
A.Gross Income (Do not list ATAP or SSI below.) Gross wages
Value of employer-provided housing/food/etc. Unemployment compensation
Permanent fund dividend Other:
TOTAL INCOME
B.Deductions Allowable Under Civil Rule 90.3 Federal, state and local income tax Social security tax or self-employment tax Medicare tax
Employment security tax Mandatory retirement contributions Mandatory union dues
Voluntary retirement contributions if plan earnings are tax-free or tax-deferred, up to 7.5% of gross wages and self-employment income when combined with mandatory contributions
Other mandatory deductions (specify)
Child support/alimony ordered in other cases and currently being paid
Child support for children from prior relationships living with this parent, calculated under Civil Rule 90.3
Work-related child care for children of this marriage
TOTAL DEDUCTIONS
C. Net Income
TOTAL INCOME from section A
TOTAL DEDUCTIONS from section B
Subtract deductions from income to get
NET INCOME
D.Adjusted Annual Income
1.If the above figures are based on monthly information, multiply NET INCOME from section C by 12 to get
ADJUSTED ANNUAL INCOME
2.If the above figures are based on yearly information, repeat the NET INCOME amount from section C to show
Page 2 of 4
RESPONDENT
III.Health Care Coverage for the Children. A. Health Insurance.
1.Does the petitioner have health insurance available for the child(ren) at reasonable cost through his/her employer, union or otherwise?
Yes
No
If yes, state name and address of employer, union or other
source through which insurance is provided or available.
Name:
Address:
Cost to petitioner: $
per
month
2.Does the respondent have health insurance available for the child(ren) at reasonable cost through his/her employer, union or otherwise?
Cost to respondent: $
3. Are the children eligible for services through the Indian Health Service?
4. Do the children have other health insurance or care available?
Yes Describe:
B.Children’s Health Care Expenses Not Covered By Insurance.
Is there any reason why the court should not require the parties to share equally the cost of reasonable health care expenses not covered by insurance?
IV. Travel Expenses. Travel expenses to exercise visitation should be allocated between the parties as follows:
Page 3 of 4
V.Immediate Income Withholding.
The Alaska Statutes require that child support be withheld from the income of the person paying support and paid through the Child Support Services Division (CSSD) unless one of the following exceptions is approved by the court:
We have made the following alternative arrangement (Note that if you receive ATAP, CSSD must agree to the arrangement):
Also, the person paying support agrees to keep the other party (or CSSD if CSSD is enforcing the order) informed of his/her current employer and the availability of employment-related health insurance coverage for the child(ren) until the support order is satisfied.
We believe there is good cause not to require immediate income withholding because it is not in the best interests of the child(ren) for the following reason:
The person paying support currently receives social security or other disability compensation that includes regular payments to the child(ren) at least equal to the child support owed each month. Monthly payment to child(ren): $
Source of payment:
Note: To the extent that these payments to the children do not satisfy the monthly amount owed, the court will order that the remaining amount due be withheld from income.
VI. If you want the assistance of the Child Support Services Division (CSSD) to enforce the support order and keep records of the payments, you must apply for CSSD services. You can get an application from CSSD or you can fill out court form DR-315 (available at the clerk’s office) and mail it to CSSD at 550 West 7th Ave., Suite 310, Anchorage, AK 99501.
Signature
Type or Print Name
Subscribed and sworn to or affirmed before me at
, Alaska
on
.
Date
(SEAL)
Clerk of Court, Notary Public or other
person authorized to administer oaths.
My commission expires:
Page 4 of 4
Incomplete Information: Many people forget to fill in all required sections of the form. Missing details can delay the process. Ensure that every section is completed, including names, dates of birth, and income information.
Incorrect Income Reporting: Some individuals misreport their income. It’s essential to provide accurate figures from your most recent tax return and pay stubs. Double-check these numbers to avoid issues.
Not Attaching Required Documents: Failing to attach necessary documents is a common mistake. Always include your most recent federal tax return and pay stubs. These documents are vital for verifying income and deductions.
Ignoring Health Care Information: Many overlook the health care section. If health insurance is available for the children, it must be reported. Provide details about coverage and any associated costs to avoid complications later.
Filling out the Alaska DV 101 form is an essential step for individuals seeking a long-term domestic violence protective order that includes child support information. Properly completing this form ensures that the court has all necessary details to make informed decisions regarding child support and related matters. Below are the steps to guide you through the process of filling out the form.
When filling out the Alaska DV 101 form, there are important steps to follow. Here’s a list of things you should and shouldn't do:
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